ANTEPARTUM HAEMORRHAGE
Obstetric Haemorrhage

Ranks as the First cause of maternal
mortality accounting for 25 – 50 % of
maternal deaths
APH: Epediology & Causes

Magnitude: 4% of women may develop APH.

Causes:
 placenta previa (1/200)
 placental abruption (1/100)
 uterine rupture (<1% in scarred uterus)
 vasa previa (1/2000-3000)
 Local causes
 Unknown origin
Vasa Previa
Velamentous Insertion of the umbilical
cord
I. ABRUPTIO PLACENTA

Definition:


Early separation of the normally implanted
placenta after 28/40 and before the end of
second stage of labour
Recurrence:

The risk of recurrent abruption in a
subsequent pregnancy is high.
Abruptio placenta: Classifications
Are based on
1.
Extent of separation: Partial vs complete
2.
Location of separation: Marginal Vs central
3.
Clinical presentation: Revealed, concealed and
mixed
4.
Clinical Severity: Mild, Moderate and Severe
Clinical Severity
Class 2: moderate -approx
27% of all cases.
Class 1 Mildest form:
approx 48% of all cases.
•
•
•
•
•
No vaginal bleeding to
mild vaginal bleeding
Slightly tender uterus
Normal maternal BP and
heart rate
No coagulopathy
(clotting problems)
No fetal distress
•
•
•
•
•
No vaginal bleeding to moderate
vaginal bleeding
Moderate-to-severe uterine
tenderness with possible tetanic
contractions
Maternal tachycardia with
orthostatic changes in BP and heart
rate
Fetal distress
Low fibrinogen levels present
(causing clotting problems)
Clinical Severity
Class 3: Severe form: Approx 24% of all cases.
• No vaginal bleeding to heavy vaginal bleeding
• Very painful tetanic uterus
• Maternal shock
• Coagulopathy
• Fetal death
I. Abruptio placenta: Risk factors

Hypertensive Disease

Multiple pregnancy

Trauma

PPROM
I. Abruptio placenta: Risk factors

Anaemia

Polyhydramnios – sudden ↓intrauterine
pressure

Short cord

Uterine leiomyoma: esp if located behind
the placental implantation site, predispose
to abruption
Abruptio Placenta: Features

Pain and tenderness

Initially localized then becomes generalized
due to endometrial injury – extravasations of
blood

Vaginal bleeding

Maternal distress

Often I.U.F.D
Placental Abruption: Complications

Shock

Acute renal failure


Cause: ?seriously impaired renal perfusion 2°
to ↓CO and intrarenal vasospasm as in
preeclampsia
DIC

Consumptive coagulopathy 2° to
hypofibrinogenemia along with elevated levels
of fibrinogen–fibrin degradation products
Placental Abruption: Complications

Fetal distress/demise

PPH

Couvelaire Uterus:

Widespread extravasation of blood into the uterine
musculature and beneath the uterine serosa.

Sheehan syndrome

Puerperal sepsis
Placental Abruption: Management

Management depends on:




fetal maturity,
degree of severity,
viability of the fetus/fetal distress
Treatment modalities



Expectant management of pregnancy
Induction/augmentation of labor
Caesarean section
Placental Abruption: General Management
1. Delivery

Resuscitation

FFP, whole blood, IV fluids

Monitor BP

Catherization - monitor urine output
Placental Abruption: General Management

ARM

Induce/Augment labour

Oxytocin infusion or prostaglandin if
necessary to induce contractions

Bed site clotting time

Done regularly
Placental Abruption: General Management
2. Caesarean Section

Indications for Caesarean Section





salvageable baby,
Severe vaginal bleeding,
Poor progress,
Transverse lie, inadequate pelvis
Post delivery -watch out for PPH

Why?
 Myometrial myofibrin loose contractility
 Failure to clot
PLACENTA PRAEVIA - DEGREES
1.
Total placenta praevia
The internal cervical os is covered
completely by placenta.
2.
Partial placenta praevia
The internal os is partially covered
by placenta.
PLACENTA PRAEVIA - DEGREES
3. Marginal placenta praevia
The edge of the placenta is at the margin of the
internal os.
4.
Low-lying placenta
The placenta is implanted in the lower uterine
segment such that the placental edge actually
does not reach the internal os but is in close
proximity to it.
PLACENTA PRAEVIA: Predisposing factors

Multiparity

Advanced maternal age

Prior C/S or other uterine surgery

Prior placenta previa
Placenta Previa: Diagnosis

Painless vaginal bleeding in 2nd/3rd trimester

Confirmed by ultrasound

Up to 10% may have simultaneous abruption

Maternal shock is uncommon with 1st
presentation of bleeding
Placenta Previa: Obstetric Management

Vaginal exams are avoided

If possible, delay delivery until fetus is mature.

 34 weeks - buy time for steroids

Prevent contractions with tocolytics -indocid

Mobilize blood donors
Placenta Previa: Obstetric Management



i.
Resuscitate - IV fluid and blood,
Monitor BP and amount of bleeding
Delivery
Mild non persistent bleeding

GA  34 weeks





ii.
Buy time for steroids and hospitalization.
Prevent contractions with tocolytics Mobilize blood donors
Oral haematenics
GA  37 weeks = consider Elective CS
Persistent bleeding requires immediate delivery
whatever the gestation
Placenta Previa: Management

Indications for delivery:






Persistent bleeding requires delivery whatever the
gestation
Active labor
Documented fetal lung maturity
 37 weeks gestational age.
Excessive bleeding
Development of another obstetric complication
mandating delivery
Placenta Praevia

Elective caesarean if  37 weeks

? Never cut through the placenta
PLACENTA PRAEVIA

Lower segment may need to be
packed

Placenta previa may be assoc. with
placenta accreta, increta or percreta →
PPH

PPH - 2° to poorly contractile nature of
the LS of uterus.
Comparison of Presentation of
Abruption v. Previa v. Rupture
Abruption Previa
Rupture
Abdominal pain
present
absent
variable
Vaginal blood
old
fresh
fresh
DIC
common
rare
rare
Fetal distress
common
rare
common
Vasa Previa

“Umbilical vessels separate in the membranes
at a distance from the placental margin and
some of the vessels (fetal) cross the internal os
and occupy a position ahead of the presenting
part of the fetus.”

ROM may cause fetal exsanguination.

High fetal mortality (50-75%)

Risk factor: multiple gestation (esp., triplets).
Vasa Praevia

Diagnosis





Moderate vag bleeding + fetal distress
Vessels may be palpable thru dilated cervix
Vessels may be visible on ultrasound
Difficult to distinguish clinically from
abruption.
Treatment

C/S,

Resuscitation of infant (volume)
Local & Unknown Causes of APH

Rupture of uterus

Carcinoma of cervix

Trauma

Cervical polyp

Bilharzia of cervix

Cervicitis